BAYPATH ELDER SERVICES AREA AGENCY ON AGING TITLE III GRANT APPLICATION FOR FFY 2019 COVER PAGE

Transcription

1 BAYPATH ELDER SERVICES AREA AGENCY ON AGING TITLE III GRANT APPLICATION FOR FFY 2019 COVER PAGE General Information: Agreement Period: October 1, September 30, 2019 Name of Project: Communities to be served: Amount of FFY'18 Title III Funding Request: $ Organization Address Federal Tax ID Number: Contact Person: Title: Print/Type Name Phone Web Site Fax Proposed Project Operating Budget: A. Title III B. Non-Federal Match (Cash) C. Non-Federal Match (In-kind) D. Other Sources (explain) E. Total Program Revenue Name of Person Authorized to Submit Proposal: Title: Signature: Date:

2 Program Narrative All elements of each question or form are to be answered completely. Missing information could jeopardize approval for funding. If part of a question appears to be non-applicable, explain why it does not apply. 1. Organizational Description of Agency/Applicant - a brief (one page maximum) description of the organization's mission, target population(s) and current programs operated. 2. Provide a brief description of the proposed program - this should include any outreach targeted to specific elder populations: e.g. minority, frail/disabled, rural, low-income, caregiver, immigrant, LGBT (lesbian, gay, bi-sexual, transgender). It should include how the proposed project will coordinate with other local programs and services. 3. Identify and document the level of need for the proposed program services in the service area - this should include local demographic and statistical data where available. 4. What strengths and/or experience will enable your organization to succeed in this activity? Identify proposed program outcomes and anticipated obstacles to program implementation and how they will be addressed. 5. Program Workplan: Appendix A: Describe the specific activities that will take place and the time frames for these activities Appendix B: Project the number of people to be served and project demographic information based on your best estimates. 6. Use the attached form (Appendix C) to outline the proposed program budget and provide a "budget justification" (Appendix D). The budget must reflect the required 15% non-federal in-kind/cash match (25% for IIIE). The budget justification should: discuss all costs reflected on the budget page with specific information as to how those costs were computed; e.g., salaries should include hourly wage, number of hours per week and number of weeks. define sources of funding for each item; e.g. federal or non-federal for the 100% budget figure. provide specific information on fringe, travel rate should be included. COA applications should specifically reference their use of Formula Grant funds. provide cash value of any in-kind contributions and how it is determined. demonstrate that no more than 10% of Title III funds are applied to indirect program costs or provide a justification for exceeding the 10% limitation.

3 7. List all staff positions for the proposed project and attach a job description, including required qualifications, for each position. 8. Describe how the program will offer participants the opportunity to make voluntary contributions and how will you maintain confidentiality when you receive these contributions? Attach a copy of the donation letter or other means used to inform program participants of the opportunity to make a donation. 9. Future Funding(sustainability)and Recognition a. Describe efforts that have or will be undertaken to secure other permanent funding for the continuation of the service initiated with Title III funds. b. Describe how Title III funding by BayPath and EOEA is (or will be) recognized. To the original application attach a copy of: Any staff licenses, and/or certifications (where required by job description). Agency s most recent audited financial statement. A copy of the agency's affirmative action policy. Evidence of liability insurance. A copy of the agency's policy regarding Americans with Disabilities Act (ADA) compliance. Any interagency agreement(s) (where applicable). Job descriptions for program/project personnel Resumes of key project personnel List of subcontractors if any, including service and amount of contract Voluntary donation policy statement Board approved agency operating budget

4 Appendix A Project Work Plan (attach as many sheets as needed) Project Goal: Objective # : Action Steps: Date: Objective # : Action Steps: Date: Objective # : Action Steps: Date:

5 Appendix B PROJECTED DEMOGRAPHIC CHARACTERISTICS State the projected number of clients to be served in each category during FFY Normally these projections should, at a minimum, reflect the proportions of these targeted groups in the program service area. A-1 Total number of unduplicated persons aged 60 years or over to be served (may be under 60 if applying for title III E funds) A-2 Projected elders by OAA specified categories a. American Indian/Alaskan Native b. Asian/Pacific Islander c. African American d. Hispanic e. Frail/Disabled (persons aged 60+ having A physical or mental disability, including having Alzheimer s Disease or a neurological or brain disorder of the Alzheimer s type, that restricts the ability of the individual to live independently). f. Resident of Rural Areas. g. Low-income non-minority (persons aged 60+ with an annual income at or below the federally established poverty level. h. Low-income Minority (persons age 60+ who are either American Indian /Alaskan Native, Asian/Pacific Islander, Black not of Hispanic origin, or Hispanic, within annual income at or below the federally established poverty level).

6 Appendix C BayPath Elder Services Area Agency on Aging Budget Form - FFY 2019 (October 1, 2018 to September 30, 2019) Revenue and Support A. Sources of Revenue and Support TITLE III: State: Local: Private: Foundations: Corporations: Client Donations: INKIND Support: Other (explain) SUB TOTAL: **GRAND TOTAL: Columns B+C: B. TITLE III request C: Amount of Other Revenue and In-kind Support XX Project Expenses: Cost Categories: Title III Non-Federal Match (Cash) Personnel: Non-Federal Match (In-kind) Total Program Costs (A)Total Personnel: (A) Support Costs: (B) Total Support (B) **GRAND TOTAL (A+B) **the Revenue/Support Total must equal Project Expenses Total

7 Appendix D Budget Justification (in detail) Revenue Line Items: Expense Line Items:

8 Application Check List To ensure your application is complete, please review and check off each of the items below and attach this Form to your proposal. The deadline for proposals is 5 p.m., Friday June 1, Submit the original and six copies of your proposal, including copies of all attachments. Cover Page Form from Application Packet Program Narrative 1 Organizational Description of Agency/Applicant, one page maximum 2 3 Brief Description of Proposed Program Statement of Need 4 Identity of Outcomes and Obstacles Program Work Plan: Appendix A and Appendix B Project Budget (Appendix C) Budget Detail (Appendix D) Amendments/Attachments 1. Needs Assessments Surveys (optional) 2. Letters of Support (optional) 3. Program Personnel job descriptions, resumes and licenses (required) 4. Voluntary Donation Policy (required) 5. Board Approved Agency Operating Budget (required) 6. Most Recent Audited Financial Statements (required ONLY NEED ONE COPY) 7. Copy of agency s affirmative action policy (required) 8. Evidence of liability insurance (required) 9. Interagency Agreements (if applicable) 10. Copy of the agency s policy regarding Americans with Disabilities Act compliance (required)